Complex trauma: how abuse and neglect can have life-long effects

article by John McAloon Senior Lecturer, Graduate School of Health at University of Technology, Sydney. Appeared in The Conversation

Experiencing trauma has significant implications for mental health. We’ve known this for some time but particularly since the early 1970s after observing and studying the effects of war on American servicemen in Vietnam. More recently, research has shown that experiencing trauma early in childhood has a significant impact on the development of the brain and the way it works.

Trauma early in childhood can result from a range of things such as living in domestically violent situations, or being raised in situations where the parent’s needs – such as drug use or alcohol abuse – influence their ability to provide for their child’s needs.

Complex trauma may come in the form of neglect. Not responding to a baby or not having the skills to do so, for instance, means the baby’s developmental needs may not be met.

Complex trauma can also come in the form of abuse. An example is when a baby who cries to convey its needs or distress is physically assaulted, instead of given food or comfort. This can result in more crying and a cycle of crying and abuse may follow.

The repeated experience of trauma early in development has been termed complex trauma.

People react to threat or danger with a system comprised of biological, cognitive and behavioural responses. The biological responses involve a cascade of interdependent neurochemical changes in different parts of the brain and body. These, in turn, influence thinking and behaviour.

Normally, following the perception of threat or danger, the body’s neurochemistry returns back to normal. In post-traumatic stress disorder (PTSD), the neurochemical responses outlive the original threat and inhibit the system’s ability to return to normal.

In people with complex trauma, research suggests that repeated exposure to traumatic events early in development not only inhibits the neural system’s ability to return to normal but changes the system to appear like one that is always anticipating or responding to trauma.

For this reason, people who have experienced complex trauma may display symptoms including poor concentration, poor attention and poor decision-making and judgement. They may also appear highly reactive and respond to threat even if it is not present. Their behaviour may be aggressive in response, or they may take flight or simply freeze.

In this way, complex trauma translates into a range of social, emotional, behavioural and interpersonal difficulties that can be life-long. The associated personal, social and economic costs are high.

Despite increased awareness in the area, complex trauma cannot be formally diagnosed. It is not a diagnostic category in the recently revised Diagnostic and Statistical Manual of Mental Disorders (DSM-5). There are no clear estimates of its prevalence in the community.

When someone who has experienced this sort of trauma tries to find help, or when they get into trouble of some sort and are required to get help as a result, the effectiveness of treatment is likely to have a lot to do with the way psychologists or psychiatrists assess the person.

But if that person has experienced complex trauma and the assessment does not recognise this, then simply treating for ADHD may well not be effective. The person’s ability to comply with treatment or medication may be limited, and other important characteristics such as associated developmental and mental health concerns may be present but overlooked.

Assessing people who seek support must involve global assessment of their development, history and functioning across different situations.

It is not surprising that children who have experienced complex trauma often grow up in families that have difficulties. These may be families that are emotionally volatile because they’re struggling with poverty, or where parents have substance use or mental health concerns. Or mum and dad may be poorly equipped to parent as a result of their own experiences as children.

These things contribute to the likelihood that the family will break down and the youngsters will find themselves in an alternative home environment. This may be with other members of their family, such as grandparents, uncles or aunts. But it may also mean that the youngsters are placed in out-of-home care that does not involve their family: either a foster care or residential care arrangement.

When a child or young person’s behaviour is particularly difficult to deal with, as it often is when young people have experienced complex trauma, multiple placements in foster care and residential care can follow, breaking down in quick succession.

If you believe a child you know is being maltreated, either neglected or abused, it is important that you contact the child protection authorities in your state. It is likely that you will be asked to make a report about the child. This can be done anonymously.

If you believe that a child is in immediate danger for whatever reason, call the police immediately.

A significant amount of effort has gone into designing effective models of care that can respond to the effects of early trauma. Evidence suggests that, for children and young people who have experienced complex trauma, effective treatment does not occur in isolation from day-to-day living. It appears that the day-to-day experiences that children and young people who have experienced complex trauma have with other people contribute significantly to their repair, recovery and ongoing development.

It is clear that the best time to do something about a problem is before it begins. Effective prevention programs have been developed and provided to parents who are known to be at increased risk of not being able to provide the best care for their children. Commonly, these programs teach parents skills in parenting, as well as skills in managing their own emotions and in providing a safe home environment.

If they are to be effective, programs that teach parents skills to better parent their children and provide their children with a good start in life need to be considered from a public health perspective. We’ve acted on other public health warnings such as nutrition, exercise, wearing seatbelts and smoking tobacco. We now need a public health agenda to prevent complex trauma.